A few years ago,
I was taking care of a woman who was a victim of violence.
I wanted her to be seen in a clinic that specialized in trauma survivors.
I made the appointment myself because, being the director of the department,
I knew if I did it,
she would get an appointment right away.
The clinic was about an hour and a half away from where she lived,
but she took down the address and agreed to go.
Unfortunately, she didn't make it to the clinic.
When I spoke to the psychiatrist,
he explained to me
that trauma survivors are often resistant
to dealing with the difficult issues that they face,
and often miss appointments.
For this reason,
they don't generally allow the doctors to make appointments for the patients.
They had made a special exception for me.
When I spoke to my patient,
she had a much simpler and less Freudian explanation
of why she didn't go to that appointment:
her ride didn't show.
Now, some of you may be thinking,
"Didn't she have some other way of getting to that clinic appointment?"
Couldn't she have taken an Uber
or called another friend?
If you're thinking that,
it's probably because you have resources.
But she didn't have enough money for an Uber,
she didn't have another friend to call.
But she did have me, and I was able to get her another appointment,
which she kept without difficulty.
She wasn't resistant, it's just her ride didn't show.
I wish I could say that this was an isolated incident,
but I know from running the safety net systems
in San Francisco, Los Angeles, and now New York City,
that health care is built on a middle class model
that often doesn't meet the needs of low-income patients.
That's one of the reasons why it's been so difficult
for us to close the disparity in health care
that exists along economy lines
despite the expansion of health insurance
under the ACA, or ObamaCare.
Health care in the United States
assumes that, besides getting across the large land expanse of Los Angeles,
it also assumes that you can take off from work
in the middle of the day to get care.
One of the patients who came to my East Los Angeles clinic
on a Thursday afternoon
presented with partial blindness
in both eyes.
Very concerned, I said to him,
"When did this develop?"
He said, "Sunday."
I said, "Sunday?
Did you think of coming sooner to clinic?"
And he said, "Well, I have to work in order to pay the rent."
A second patient to that same clinic,
a trucker,
drove three days with a raging infection,
only coming to see me after he had delivered his merchandise.
Both patients' care was jeopardized by their delays in seeking care.
Health care in the United States assumes that you speak English
or can bring someone with you who can.
In San Francisco, I took care of a patient on the inpatient service
who was from West Africa
and spoke a dialect so unusual
that we could only find one translator on the telephonic line
who could understand him,
and that translator only worked one afternoon a week.
Unfortunately, my patient needed translation services every day.
Health care in the United States assumes that you are literate.
I learned that a patient of mine who spoke English without accent
was illiterate
when he asked me to please sign a social security disability form
for him right away.
The form need to go to the office that same day,
and I wasn't in clinic,
so trying to help him out,
knowing that he was the sole caretaker of his son,
I said, "Well, bring the form to my administrative office.
I'll sign it and I'll fax it in for you."
He took the two buses to my office,
dropped off the form,
went back home to take care of his son,
I got to the office, and what did I find next to the big "X" on the form?
The word "applicant."
He needed to sign the form.
And so now I had to have him take the two buses back to the office
and sign the form so that we could then fax it in for him.
It completely changed how I took care of him.
I made sure that I always went over instructions verbally with him.
It also made me think about all of the patients
who receive reams and reams of paper
spit out by our modern electronic health record systems
explaining their diagnoses and their treatments,
and wondering how many people actually
can understand what's on those pieces of paper.
Health care in the United States assumes that you have a working telephone
and an accurate address.
The proliferation of inexpensive cell phones
has actually helped quite a lot,
but still my patients run out of minutes
and their phones get disconnected.
Low-income people often have to move around a lot by necessity.
I remember reviewing a chart of a woman with an abnormality on her mammogram.
That chart assiduously documents that three letters were sent to her home
asking her to please come in for followup.
Of course, if the address isn't accurate,
it doesn't much matter how many letters you send to that same address.
Health care in the United States assumes that you have a steady supply of food.
This is particularly an issue for diabetics.
We give them medications that lower their blood sugar.
On days when they don't have enough food,
it puts them at risk for a life-threatening side effect
of hypoglycemia, or low blood sugar.
Health care in the United States assumes that you have a home
with a refrigerator for your insulin,
a bathroom where you can wash up,
a bed where you can sleep without worrying about violence
while you are resting.
But what if you don't have that?
What if you live on the streets,
you live under the freeway,
you live in a congregant shelter
where every morning you have to leave at 7 or 8 am?
Where do you store your medicines?
Where do you use the bathroom?
How do you put your legs up if you have congestive heart failure?
Is it any wonder that providing people with health insurance who are homeless
does not erase the huge disparity
between the homeless and the housed?
Health care in the United States assumes that you prioritize your health care,
but what about all of you?
Let me assume for a moment that you're all taking a medication.
Maybe it's for high blood pressure.
Maybe it's for diabetes or depression.
What if tonight you had a choice:
you could have your medication but live on the street,
or you could be housed in your home but not have your medication?
Which would you choose?
I know which one I would choose.
This is just a graphic example of the kinds of choices
that low-income patients have to make every day.
So when my doctors shake their heads and say,
"I don't know why that patient didn't keep his followup appointments,"
"I don't know why she didn't go for that exam that I ordered,"
I think, well, maybe her ride didn't show,
or maybe he had to work.
But also, maybe there was something more important that day
than their high blood pressure or a screening colonoscopy.
Maybe that patient was dealing with an abusive spouse
or a daughter who is pregnant and drug-addicted,
or a son who was kicked out of school,
or even maybe they were riding their bicycle through an intersection
and got hit by a truck,
and now they're using a wheelchair and have very limited mobility.
Obviously, these things also happen to middle class people,
but when they do,
we have resources that enable us to deal with these problems.
We also have the belief that we will live out our normal lifespans.
That's not true for low-income people.
They've seen their friends and relatives die young of accidents, of violence,
of cancers that should have been diagnosed at an earlier stage.
It can lead to a sense of hopelessness,
that it doesn't really matter what you do.
I know I've painted a bleak picture of the care of low-income patients,
but I want you to know how rewarding I find it
to work in a safety net system
and my deep belief that we can make the system responsive
to the needs of low-income patients.
The starting point has to be to meet patients where they are,
provide services without obstacles,
and provide patients what they need,
not what we think they need.
It's impossible for me to take good care of a patient
who is homeless and living on the street.
The right prescription for a homeless patient is housing.
In Los Angeles, we have 4,700 chronically homeless persons
suffering from medical illness,
mental illness, addiction.
When we house them, we found that overall health care costs,
including the housing, decreased.
That's because they had many fewer hospital visits,
both in the emergency room and on the inpatient service.
And we gave them back their dignity.
No extra charge for that.
For people who do not have a steady supply of food,
especially those who are diabetic,
safety net systems are experimenting with a variety of solutions,
including food pantries at primary care clinics,
distributing maps of community food banks and soup kitchens.
And in New York City,
we've hired a bunch of enrollers
to get our patients
into the supplemental nutrition program known as food stamps to most people.
When patients and doctors don't understand each other,
mistakes will occur.
For non-English-speaking patients, translation is as important
as a prescription pad, perhaps more important.
And, you know, it doesn't cost anything more
to put all of the materials at the level of fourth-grade reading
so that everybody can understand what's being said.
But more than anything else, I think low-income patients
benefit from having a primary care doctor.
Mind you, I think middle class people also benefit from having somebody
to quarterback their care,
but when they don't, they have others who can advocate for them,
who can get them that disability placard,
or make sure the disability application is completed.
But low-income people really need a team of people who can help them
to access the medical and non-medical services that they need.
Also, many low-income people are disenfranchised
from other community supports,
and they really benefit from the care and continuity provided by primary care.
A primary care doctor I particularly admire
once told me how she believed that her relationship with a patient
over a decade was the only healthy relationship
that that patient had in her life.
The good news is, you don't actually have to be a doctor
to provide that special sauce of care and continuity.
This was really brought home to me when one of my own long-term patients
died at an outside hospital.
I had to tell the other doctors and nurses in my clinic
that he had passed.
But I didn't know that in another part of our clinic,
on a different floor,
there was a registration clerk
who had developed a very special relationship
with my patient every time he came in for an appointment.
When she learned three weeks later that he had died,
she came and found me in my examining room,
tears streaming down her cheeks,
talking about my patient
and the memories that she had of him,
the kinds of discussions that they had had about their lives together.
My patient had a hard life.
He was by his own admission a gangbanger.
He had spent substantial amount of time in prison.
He suffered from a very serious illness.
He was a drug addict.
But despite all that, he rarely missed a visit,
and I like to believe that was because he knew at our clinic that he was loved.
When our health care systems have the same commitment to low-income patients
that that man had to us,
two things will happen.
First, the system will be responsive to the needs of low-income people.
It will speak their language, it will meet their schedules,
it will fulfill their needs.
Second, we will be providing the kind of care
that we went into this profession to do,
not just checking the boxes
but really taking care of those we serve.
Thank you.
(Applause)